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situation with a general clinician, it’s certainly not very good. There’s still a real problem, and it’s not clear how to solve the problem.” 9 Here Spitzer admits something upon which many within the profession agree: that diagnostic reliability, despite the reforms, is still woefully low.
    According to a study published in the journal Psychiatry in 2007 that asked a group of psychiatrists whether they thought psychiatric diagnosis was now reliable, a full 86 percent said that reliability was still poor. 10 It was not only their clinical experience that led them to this conclusion, but also presumably their familiarity with existing research, including work undertaken by Spitzer himself to find out whether his reforms had worked. Its conclusions were not reassuring.
    You’ll remember I said that before Spitzer’s DSM-III , two psychiatrists would give different diagnoses to the same patient 32 percent to 42 percent of the time. Spitzer found that after his reforms, psychiatrists were now disagreeing around 33 percent to 46 percent of the time—results indicating the very opposite of diagnostic improvement. 11 And these disappointing figures are consistent with other, more recent studies that also implied reliability is still poor. For example, another study published in 2006 showed that reliability actually has not improved in thirty years. 12
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    An obvious question for the British reader is whether poor diagnostic reliability is a problem in the UK After all, in the UK we have, alongside the DSM , the International Classification of Diseases (the ICD ). Perhaps the ICD leads to greater reliability than the DSM ? Although this is a reasonable question to ask, when we take the research en masse, it actually shows that using the ICD leads to no greater diagnostic reliability than using the DSM . 13 This partly explains why in countries like Britain where the ICD is used alongside the DSM , many mental health researchers and professionals often prefer the DSM . 14 In fact, the National Institute for Clinical Excellence (the body that sets the clinical guidelines for the National Health Service in the UK) now recommends the use of the DSM over the ICD for disorders including depression. 15 Also, in my own experience working in the NHS, the DSM is very much an influential manual. But even if you wanted to dispute its precise impact, as an article in the British Journal of Psychiatry put it, in Britain “we’d still not avoid all the problems that beset the DSM .”
    Both manuals were developed and classify mental disorders in pretty much the same way. According to the DSM , “The many consultations between the developers of the DSM-IV and the ICD-10 … were enormously useful in increasing the congruence and reducing meaningless differences in working between the two systems.” 16 Herbert Pardes also confirmed this to me when recounting that “the DSM worked very closely with the ICD to get worldwide cooperation between diagnostic categories.” In other words, diagnostic reliability is a problem for American psychiatry—whichever manual you employ, the reliability rates are broadly the same.
    This leads me to one final point about the reliability problem that would be perilous to overlook: What would happen if some day reliability rates in psychiatry were to dramatically improve? This question is important because it reveals a more fundamental problem for psychiatry that it has yet to solve: even if every psychiatrist on the globe independently diagnosed the same patient with the same disorder (for example, with “social anxiety disorder”), this would still not prove that social anxiety disorder actually exists in nature, that it is actually a discrete, identifiable, biological disease or malfunction of the brain. It needs much more than mere agreement to prove that. It requires hard evidence. After all, many experts once agreed the world was flat, but